Friday, January 20, 2012

Another Trip To The Moon

The young man walking in the door looked vaguely familiar. I glanced down at the computer screen sitting on my lap, and clicked through the visit history. I had never seen him in the office before. I studied the landscape of his face searching each wrinkle and furrow for the hint that would unhinge the avalanche of memory. He looked up at me quizzically and our eyes met.

You don't remember, do you?

By now my embarrassment was replaced by curiosity. He proceeded to explain that he had seen me as a patient ten years ago in my previous office. I marveled at the idea of time passed. A decade younger, I had just married and my kids weren't even born yet.

I was a recent graduate then. Wet under the ears and fresh out of training, medicine was more like a space odyssey; a trip to the moon. I marveled at each new patient, each diagnosis. The unflappable professional cynicism had not yet mushroomed into the all consuming giant that it eventually would.

As my reverie cleared, I began to populate the electronic medical record at a rapid pace. I discussed the intricacies of his medical history and paused occasionally to tease out details. His previous diagnosis of ehrlichia intrigued me. A tick born illness, known to cause fever and rash, that is notoriously difficult to diagnose. I probed further.

Tell me about how your ehrlichia was diagnosed?

His face broke into a grin and he started to laugh. He thought I was kidding, but then realized I was serious and cleared his throat.

It was you. After two emergency rooms and one primary care doctor missed it, you put me on medication, and everything got better.

I was stunned. Not only had I forgotten the patient, I had lost all memory of making the appropriate diagnosis. I had only seen a few cases of this disease in my life, you would think that I would remember each one.

The next day, I scoured the medical records department for the old paper chart. As I read through the hand written pages, I couldn't believe my eyes. My admitting note mentioned ehrlichia as a probable diagnosis, and I started the appropriate antibiotics immediately.

Years later, I am often stunned by how much medicine I have learned and forgotten over time. If the same case presented to me today, would I divine the right diagnosis?

The practice of medicine blinds us with the haze of familiarity. New attendings remember their recent residency training and often are up to date on even the most obscure diseases. But as time goes by, what we gain in experience we lose in knowledge of the long tail.

It has been said that physicians spend the majority of their career learning.